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Thursday, August 2, 2012

EHR Template Design

It is vital that the provider plays an active role in designing the templates that he or she will use for chart documentation. However, many providers express that they don't know where to start. It is important to have a strategy so that the templates are complete, flow, and don't become a hindrance to the provider's work flow.

Unintentional risks of poor template design:

1. Higher Level E&M Codes
- Templates should represent all levels of E&M services for both new and established patients.

2. Templates that are not customizable
- Include "other" fields or space for free text so that each note is personalized to the patient.

3. Cloned Documentation
- Do not copy/paste an entire note. Only copy/paste the data that will not change.

4. Developing Documentation Bad Habits
- Documenting the same things on every patient; Using Copy/Paste from Previous Visits
Incorrectly; Temptation of Shortcuts; Authenticating/Signing Notes without reviewing.

5. Unclear Authentication of who performed which portion of the Patient Encounter/Chart Note
- All involved in patient documentation must list name/credentials/date/signature on the note.

Four Basic Principles for Good Template Design

1. Contrast
- Use bold, italics, different font sizes, and different colors to differentiate headers from non- headers and content.

3. Alignment
- Nothing should be placed on the template just because there happens to be open space.
Everything should be aligned, evenly spaced, and there should be visual connection from
start to finish.

4. Proximity
- Space to respond or elaborate via free text should be close to the template items that it
relates too.

One last helpful hint:

Apply the 80/20 rule. The most common content, which you feel is going to be used 80% of the time should be in the template. The other 20%, that is only used a smaller percentage of the time should be free texted so that the note is personalized to the patient.

Remember not to let templates drive your documentation and E&M code choices. Clinical judgement needs to be the driver! The only person that can do that is the Provider!

28 comments:

I appreciate the work here, I was familiar with some of these, but Design Instruct is becoming a new favorite of mine now! I don’t know what I would do for projects without sources of inspiration like these blogs.

It is important to avoid confusion as much as possible, especially when it comes to the names of the practitioners who performed this or that. It will surely not be helpful to refer to it for future reference.

Hey, nice share! Very useful information about EHR template design that is relevant to Medical Billing Services. EHR template design is an important factor to create a good chart documentation. The flow in between all the levels of E&M services must be consistent and easy. Your post is useful for me, i am going to bookmark this one for future reference.

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When it comes to creating and customizing EHR templates, there is a temptation to minimize the amount of unstructured data by increasing the number of checkboxes and other structured fields. While structured data is certainly valuable and a cornerstone of many of activities performed by primary care physicians, this approach to EHR templates could prove detrimental to other providers, particularly specialists, who have no need for many of the features comprising some of the more popular EHR systems.

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